This Continuing Education course will provide the Healthcare Provider with
two (2) Contact Hours of Continuing Education units (2 CEUs) that may be used
for their license or certification requirement for continuing education.

This course will cover such issues as various documentation formats and
principles of various forms of documentation. Common mistakes in charting
to avoid will be addressed. Recommendations will be presented to assist in
quality medical record keeping and documentation.

COURSE OBJECTIVES

The goal of this training program is to help the Healthcare Provider to
document properly. This program will help to identify preventable errors
of documentation and describe how to document correctly in order to provide a
safer health care environment for the patient.

After you study the information presented here, you will be able to:

∑

Identify avoidable medical documentation errors.

∑

Provide constructive changes to prevent such errors.

∑

Correct medical documentation errors or change a record for
the right reason and in the right way.

∑

Provide a safer health care environment for the patient by
documenting proactively.

COURSE REQUIREMENTS

Satisfactory completion of this two hour Medical Record and Documentation
course will earn the participant two Contact Hours of Continuing Education.
The participant must successfully pass the post course written examination with
a minimum score of 80% and complete the post course evaluation form. A
course completion certificate will be issued after all course completion
requirements are met.

Medical Records and Documentation

Medical records are legal documents, whether in written form or as a
computer-generated form. Medical Records provide proof of the care patients
receive including the response to that care. More recently, the Medical
Record is referred to as the Clinical Record consisting of all of the
contributions from each health care provider providing care to that patient.
To protect you legally you must follow the established rules of documentation
and know how to document properly.

The development of specific medical documentation guidelines falls primarily
to professional organizations such as the American Nurses Association (ANA) and
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Other rules are governed by such agencies as: the Health Care Financing
Administration (HCFA), the Agency for Healthcare Administration (AHCA),
Medicare, and Medicaid. The regulations require medical records to be kept
for every patient and these records must contain specific information to justify
the diagnosis and treatment provided.

Every medical person (doctors, nurses, therapists, etc) adds their own
documentation information within the Medical Record. Medical Records
provides a means of continued communication for all medical care providers that
render any care or treatment to the patient.

Patient data is used for claims payment, utilization review, underwriting and
coverage decisions, and litigation. Health care providers use the data for
research, to collect reimbursement, manage diagnosis and treatment, conduct
quality assurance, and monitor other providers.

The Medical Record generally contains a Patient Face Sheet describing the
patient such as the patientís true name, address, age, social security number,
physician, diagnosis, and the name of patientís insurance carrier. It also
contains the next of kin. The Medical Record generally has Physician Orders and
Physician Progress Notes that the doctor documents after reviewing the chart and
the patient. It will also contain the Nursing Record that may include the
Intake and Output Record, vital signs documentation, and the Nurseís Progress
Notes. Frequently other sections may include; the Medication Record, Xray
Record, Laboratory Record, Physical Therapy Record, the Surgical Record and any
other section for any other referred specialties.

Medical Records that are poorly maintained, incomplete, inaccurate, illegible
or altered create doubt regarding the treatment given to the patient and can
cause a jury to find the health care provider lliable. The idea behind
documentation is to provide communication for the patientís benefit, your
protection, and the protection of your facility. There is an old saying in
the medical industry, "If it was not documentedÖit was not done". This
statement is so very true and therefore to verify what you as a healthcare
provider have performed, you must always describe and document your care or
treatment to the patient or client correctly.

Documentation Formats

Although each facility may have their own method of maintaining their
patientís records, there are several basic methods of organizing the Medical
Record. One approach is the traditional narrative approach resulting in a
chronological order of the care rendered.

Narrative Charting

This method of documentation consists of a straight forward account of the
patientís status, nursing interventions performed, and the patientís true
response to those interventions. Charting is in the form of Progress Notes and
Flow Sheets and will frequently accompany the Progress Notes.

This method may not always be the best approach as it provides no logical
order for reviewing the patientís problems. Although this method of charting is
quite simple, it usually takes a longer time to actually perform.

Problem Oriented Charting

A second approach to charting is the "Problem Oriented Medical Record (POMR).
The PMOR has several components including: a compilation of the patientís
baseline information, a problems list, a plan for each designated problem, and
progress notes to define the progress of the patient.

A common method of this type of charting is the "SOAP" Method of charting.
This method focuses on the patientís problems and provides a structure to
address those problems. The SOAP Charting consists of the following:

A Ė
Assessment (Your conclusion based on subjective and objective data)

P Ė Plan
of Action (Your proposed interventions to solve the problem)

PIE Charting

PIE charting consists of a running list of nursing diagnoses, each with a
progress note. Each entry is divided into three categories. "P" is labeled
as a Nursing Diagnosis. "I" is labeled for the interventions the
healthcare provider provided, and the "E" is the determination of the success of
the intervention provided.

PIE charting provides a logical and easy to use format. PIE charting
permits you to document nursing process however it does not provide a central
point for documenting planned care. Therefore you would have to read
several "shiftsí notes to verify all of the nursing actions performed for ach
problem which is the major drawback to this method of documentation and
charting.

Focus Charting

Focus charting is typically organized by key words listed in columns.
These words may be a sign or symptom, a nursing diagnosis, a specific patient
behavior, a significant event that happened to the patient, and or a change in
the patientís present condition. In one column is the key word and in the
next column is the note on that subject including the actions you take including
the patientís response. Although this method is sometimes more complex it often
requires less written notations than the SOAP or PIE charting methods.
Some nurses believe this method of charting makes it easier to actually document
the true nursing process.

Charting by Exception

This method of charting requires that you document only significant changes
or exceptions to the patientís norms. These norms are based on
clearly defined standards of practice for nursing assessments and the
interventions you provided.

Specifically designed Flow Sheets are utilized in this form of medical
charting and documentation. You typically document explanations of the
exceptions to the norm in written progress notes.

Although this method of documentation is more involved, charting by Exception
frequently streamlines documentation and often saves time in actual charting
time.

Computerized Charting

Since the evolution of computers, new formats of documentation have been
developed. The trend today is a move towards computer based documentation
process to maintain the Medical Record. If your facility has not moved to a
computerized method of documentation, get prepared as it probably will sometime
in the near future.

Healthcare facilities utilize the computer systems for a variety of medical
related issues to include: medical billing, payroll, pharmacy supply, central
supply ordering and much more. Many hospitals now use specially designed
computerized systems called Hospital Information Systems (HIS) that include
Nursing Information Systems (NIS). These systems allow the
healthcare provider to perform a variety of tasks such as: generating Kardex
forms, Vital Sign Reports, specific charting and assessment forms, Intake and
Output Forms, Medication Sheets and much more.

The major advantage of computerized documentation is that a large volume of
information is available quickly to the Healthcare Provider. Personal
computers or bedside computer terminals are frequently located in nursing
stations and some are even located at the patientís bedside.

To use the computer system, the Healthcare Provider must "Log on" with their
Identification or Personal Identification Number (PIN). This number is assigned
to you by the facility. Then you choose the specific function that is needed
such as entering new data on the patient or retrieving past information such as
laboratory values or pharmacy orders. Using the computer method allows the
healthcare provider to retrieve much more information quicker and easier than
more conventional charting methods that would normally be more difficult and
time Ėconsuming to retrieve.

Once the information has been imputed into the system, the information is
available to all of those medical personnel having permitted access to the
patientís records. Some systems do restrict individuals from having
complete access and allows that person only to access what the hospital allows.
An example might be nurses would be allowed to access medical records however
they may not be able to access the personal billing records of the patient.

Elements of Good Documentation

Prevent medical errors by documenting defensively. The following advice
on documentation includes issues identified through analysis of malpractice
claims.

1.
Make sure you have the correct chart before you begin
documenting your entries.

2.Write legibly
and neatly, print if necessary. Date and time your entries, and sign them
correctly: the first name or initial, last name, and professional credential
(RN, LPN, CNA, and so on).

3.Avoid grammatical and spelling errors; they
make it hard to portray you as an educated professional.

4.Abbreviations are easily confused. The
indiscriminate use of abbreviations can be extremely dangerous to you and the
patient, besides being a major waste of time. The less space you have for
documentation, the more inclined you may be to abbreviate. Be extremely
careful when using flow sheets, as theyíre a breaking ground for unapproved
abbreviations. The tendency is to force a lot of information into small
spaces, thereby avoiding having to document in the progress note.
Use only proper and accepted abbreviations approved and used by your facility
and/or profession. Avoid misleading abbreviations. Next time you
start to write an abbreviation, think about it. Ask yourself if it is in
the best interest of the patient, yourself, and your facility.

5.Be factual and descriptive. Use objective
information. Rely on what you see, hear, feel or smell. Subjective
data, such as patient comments, should be entered in quotes. Record the
exact words as much as possible. Provide clear, concise, accurate
information.

6.Donít guess, generalize or
write personal opinions or statements.

7.Make sure entries are accurately dated and
timed. If you forgot to chart during a shift, make a "late entry" by writing the
current date and time in the next available space and writing "Late entry for
(date and shift missed)." To add information to an existing entry, write
the date and time of the new entry on the next available space and include:
"Addendum to note of (date and time of prior note)." Sign the entry as
usual. Donít try to squeeze in an entry between the lines.

8.Always document with a jury in mind.
Donít try to change the chart with the intent to deceive. Even if there
are other mitigating circumstances, one piece of falsified documentation casts
doubt on the entire record and can easily render a malpractice case
indefensible.

9.Do not erase, write over, or obliterate any
entries in the chart. This is illegal charting. When incorrect
information is written, draw a single line through the entry, date it, initial
it, and then enter the correct information.

10.Chart procedures and tests only
after they are done, not in advance.

11.Record the patientís symptoms and what you did
in response to the problem, whether your action involved direct patient care or
not. How did the patient respond to your interventions? Your
charting should accurately reflect the patientís condition.

12.Note communication among all health care team
members. Always document the date, time, and information conveyed, the
name of the person notified, and his or her response. Do not write vague
notations such as "MD notified" or "family notified" as this can lead to
confusion if that person needs to be identified. Avoid writing "Dr.
called" as this can easily be misinterpreted to mean that some doctor called
you.

13.If an Informed Consent is required, make sure
you know both the state law and your hospitals policy. In general,
document that the procedure was explained and that the patient knowingly
consented to it. If the patient has a guardian, document the guardianship
in your notes. If the patient is a minor, document the facts of who
signed. If the patient doesnít speak English, make sure you document the
translatorís name on the consent form and in the Nursesí Note. If the
patientís condition impairs his/her ability to give informed consent, document
the observations, alert the doctor, and follow the state law and hospital
policy.

14.Chart all instances of patient noncompliance or
refusal of recommended treatment. Document that the patient was informed
of the risks by not consenting and document his/her refusal. Then notify
your nurse-manager and the doctor.

15.Transfer and discharge documentation includes
medications, patient status (vital signs and health stability), and any teaching
and or instructions given to the patient and his/her family members/guardian
upon discharge. Carefully and thoroughly document each action in the
patientís chart.

16.Protect your signature.
Do not leave any blank spaces before you signature on a chart. Draw a line
between spaces to your name, if necessary.

17.If your facility allows charting by exception by
utilizing flow sheets for documentation, fill out all spaces on these sheets
even if itís only "N/A" for items that are not applicable or by drawing one
single line through areas not utilized. Blank spaces raise doubts about whether
something was performed or not.

Common Charting Mistakes to Avoid

Another side to medical documentation errors are the omission of
documentation of patient information pertinent to their hospitalization, safety,
and plan-of-care. The following are the most common charting mistakes
which can lead to medical errors.

1.Failing to record pertinent health or drug
information - Examples could include failing to include an allergy to
medications or food, specific histories such as Diabetes, Glaucoma,
Deafness, mental health disorders, etc. Make sure all allergies and
pertinent health information is obtained on admission and is documented
on the appropriate sheets according to your hospital policy.

2.Failing to record nursing actions - Record
everything you do for a patient on his/her chart as soon as possible.
For example, if the information regarding a dressing change is omitted,
one might not realize that the patientís wound is draining more than it
should or the nurse failed to change the dressing.

3.Failing to record that medications have
been given - Record every medication when you give it, when itís given,
and include the dose, route and time. An example of an medical
error would be administering a second dose of a medication when there
was no documentation that the ordered dose was already given.

4.Recording on the wrong chart - Check your
facilities policy on the system for flagging patientsí charts and
medication records with similar names or other similar information that
could cause confusion. Also be careful in regard to patients in
the same room having the same doctor or the same condition.

5.Failing to document a discontinued
medication - If the patient is supposed to be taken off a specific
medication, you need to document the order promptly. For example,
if a medication is to be discontinued due to an adverse effect (such as
a patient with an active bleeding ulcer who should not receive anymore
aspirin), the continuation of administering more aspirin could lead to a
deterioration of his/her condition.

6.Failing to record drug reactions or
changes in the patientís current condition - You need to document your
observation of the patientís current health condition and your specific
actions if any were taken, as well as documenting any patientís comments
about his/or her changes in their condition..

7.Transcribing orders improperly or
transcribing improper orders - Anytime you are unsure about a drug
order, check it with the prescribing doctor, your nurse manager or
follow the policy of your facility.

8.Writing illegible or incomplete
records - Imagine your embarrassment at being called to testify and not
being able to read your own handwriting or having to admit that the
information recorded is incomplete. To play it safe, remember each
of these good charting practices:

∑

Print if your handwriting is difficult to read.

∑

Sign your full name and title somewhere on every page
where youíve finished charted.

∑

Do not leave blank
spaces, lines, or boxes on charts. If you donít use the
space, draw a line through it or write N/A (not applicable).

∑

Do not use abbreviations that are not on your facilityís
approved list Document enough to convince a reader that the patient was
adequately treated or cared for.

What Not to put in a Medical Record

If an incident occurs involving the patient, the healthcare provider must
need to know "what does get documented" and just as importantly Ďwhat does not
get charted" in the Medical Record. The rule of thumb is that anytime a
patient makes a specific complaint, it should be documented. If any error occurs
such as a medication error, a medical device malfunctions, the patient or anyone
else including staff member or visitor is injured or involved in a situation
with the potential for injury, an Incident or Occurrence Report is required to
be completed.

The clinical observations of only the patient are recorded in the patientís
Medical Record. Make no mention of the "Incident Reportí in the patientís
Medical Record. The Incident Report is an administrative Risk Management
document and not part of the patientís Medical Record.

When documenting on the Medical Record, be certain to state only the facts
and not speculations. Example: You found the patient next to their bed on
the floor. Therefore, you would document "Patient found on floor", state your
assessment, any change in the patientís level of consciousness, and any
treatment provided. You would also document reporting the event to your nursing
supervisor or by calling the doctor. If you would have documented "patient
fell out of bed onto the floor" it would be assumed you actually saw the patient
fall to the floor. Since you did not see the patient climb over the side
rails and actually fall, what you actually document is "the patient was found on
the floor and whether the bedside rails were up or down" RememberÖ
No Assumptions !

This segment is just to remind you of the importance of documenting incidents
or unusual occurrences and the importance of documenting proper information on
the proper forms. Please refer to your facilityís actual policy and
procedure guidelines in regard to any other information about incident/unusual
occurrence reports or contact your nurse manager for further assistance.

Documentation Compliance Requirements

In order for a medically licensed healthcare facility to assure proper
payment for the services rendered, proper documentation justifying the care
given must be clearly provided in the Medical Record. The Medical Record
provides the evidence of which payment decisions are made. Insurance
carriers as well as Medicare and Medicaid each require strict documentation
compliance for payment reimbursement.

The Medical Record must also show the organizational process of how care was
rendered to the patient. Because the Medical Record may be shared by
several healthcare providers, it is important to understand the need for proper
and legible documentation. The Medical Record supports the patientís
eligibility for medical coverage.

As an example, for Medicare reimbursement, Medicare requires the following:

1. Patient Assessment tools must be used to reflect whether
assessments were completed within a required period of time.

2. Documentation that shows the patient has been informed of
their "Rights" including the OASIS Privacy Notice about Advance
Directives

3. A Plan of Care (POC) must be implemented describing the treatments
and services that are to be provided

4.Clinical Notes
must be completed by the healthcare Provider rendering the care and that
physicians were notified when changes in the patient status occurs.

5.Documentation
of care coordination between all of the disciplines of the patientís
health care team

Medical Record compliance is frequently evaluated by various Compliance
Surveyors that inspect the facility for licensing, accreditation, and or proper
compliance. Surveyors use various guidelines to determine complete compliance.

Medical records are closely examined for proper documentation and assure the
records meet the accreditationís guidelines. If the clinical records fail to
reflect compliance, the Surveyor then goes deeper into the facilityís policies
and or procedures to determine why the healthcare services does not meet the
established standards. If the documentation is not accurate, the billed services
may be reduced or completely denied, and the facility may be cited, fined, and
or closed.

Privacy of the Medical Record

Back on April 14, 2003, the first-ever federal privacy set of standards to
protect patients' medical records and other health information provided to
health plans, doctors, hospitals and other health care providers became
effective. The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
requires all health organizations to adopt and develop standard code sets to be
used in all health related transactions. These policies and procedures should
protect the confidentiality of protected health information about their
patients. Virtually all health providers must implement these standards if they
transact and communicate using paper, by phone or fax. Although these
requirements may allow for some flexibility, each provider must implement them
as appropriate for their own facility.

Patients do have the right to view their own medical records. Although
specific arrangements are usually made available to the patient when viewing the
medical record, patients also do have the right to make photocopies.
However, the patient may be charged for the costs of copying or mailing the
records. Employees must be trained in the specific privacy procedures
policies their facility uses.

Typically a patient will receive a Notice of Privacy upon admission. The
Notice will outline the "patientís rights. These Patient Rights will
include but are not limited to the following:

a. The right to access their
medical records

b. The right to amend their record
if contains errors

c. The right to confidential
communication

d. The right to privacy

e. The right to Opt Out of
the Directory

Information may be shared with other treatment providers such as office
staff, physicians, and other treatment facilities if there is a need to know.

In Conclusion

Attention to the quality of the medical record is everyoneís responsibility
from the doctors writing the Physician Orders, to the Nursing Assistants that
document the vital signs and Intake and Outputs, including record keeping and
billing personnel who file the claims. All administrative personnel that
maintain the Medical Records must be accountable.

Only by proper documentation by all of the healthcare team can the patient
expect a quality outcome. Continued improvement in documentation must be
maintained to assure quality patient care and to always reduce the liability of
the healthcare provider should there be question. Remember to always
document as if your documentation was being read in court, it just might be.